Optimising rapid on-site evaluation-assisted endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal lymph nodes: The real-time cytopathology intervention process.

INTRODUCTION: Lymph node sampling by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the state of art procedure for staging the mediastinum and hilar regions in lung cancer patients. Our experience of implementing the real-time cytopathology intervention (RTCI) process for intraoperative EBUS-TBNAs is presented. This study is aimed to describe in detail the RTCI process for EBUS-TBNAs, and assess its utility and diagnostic yield before and after its implementation in parallel to conventional rapid on-site evaluation (c-ROSE). METHODS: A retrospective review of all EBUS-TBNAs between July 2016 and July 2017 at the University of Rochester Medical Center was performed. Final diagnoses, patient clinical data, and number of non-diagnostic samples (NDS) were reviewed. The numbers of NDS obtained from EBUS-TBNAs with no cytology assistance (NCA), with RTCI and with c-ROSE were analysed. RESULTS: Non-diagnostic lymph node samples were found in 20 out of 116 (17%), three out of 114 (2.6%) and 33 out of 286 (11.5%) cases with NCA, RTCI and c-ROSE, respectively. Application of statistical analysis revealed significant difference in the NDS between the groups of cases in the operating room with NCA and RTCI (P = .005). The different settings and variables between the cases performed using RTCI in the operating room and those assisted with c-ROSE in the bronchoscopy suite preclude legitimate comparison. CONCLUSION: Our results indicate that the use of RTCI could yield a significantly low proportion of NDS when assisting EBUS-TBNA of mediastinal and hilar lymph node for lung cancer patients enhancing the diagnostic efficiency of the procedure.

Continuous versus discontinuous tumor involvement: A dilemma in prostate biopsy quantitation.

BACKGROUND: No consensus has been reached for an optimal method of quantifying discontinuous tumor foci separated by intervening benign tissue on prostate biopsy (PBx). We examined sets of PBx, where cancer involved only one core, and corresponding radical prostatectomy (RP) specimens. METHODS AND RESULTS: Cases were divided into 3 groups-Group 1 (n = 80): <3 mm in end-to-end tumor measurement (continuous/discontinuous); Group 2 (n = 22): ≥3 mm in tumor length (continuous); and Group 3 (n = 15): ≥3 mm in end-to-end tumor measurement (discontinuous). The rate of Gleason score ≥7 was considerably lower in Group 1 (9%/30% on PBx/RP) than in Group 2 (50% [P < 0.001]/59% [P = 0.015] on PBx/RP) or Group 3 (40% [P = 0.005]/46% [P = 0.237] on PBx/RP). pT2 disease was significantly more often found in Group 1 (88%) than in Group 2 (68%, P = 0.049) or Group 3 (60%, P = 0.018). Surgical margin was significantly more often positive in Group 3 (27%) than in Group 1 (5%, P = 0.020), but not Group 2 (9%, P = 0.198). Moreover, estimated cancer volume (cc, mean ± SD) was significantly smaller in Group 1 (1.89 ± 1.98) than in Group 2 (3.56 ± 2.92, P = 0.026) or Group 3 (3.44 ± 2.02, P = 0.013). Kaplan-Meier analysis revealed higher risks of biochemical recurrence after RP in Group 2, compared with Group 1 (P = 0.001) or Group 3 (P = 0.096). In 93 patients with biopsy Gleason score 6 cancer, higher rates of pT2+/3 disease (P = 0.023) and positive margin (P = 0.026), as well as larger cancer volume (P = 0.063), on RP were still seen in Group 3, compared with Group 1, but their differences were not statistically significant between Group 2 and Group 3. CONCLUSIONS: Linear quantitation including intervening benign tissue on PBx may more precisely predict the actual tumor extent.

Intraoperative Cytology for Video-Assisted Thoracic Surgery: A Quality Improvement Analysis.

BACKGROUND: Frozen section is a standard of care procedure during thoracic surgery when an immediate diagnosis is needed. An alternative procedure is intraoperative cytology. Video-assisted thoracic surgery is currently widely used for thoracic surgical procedures. The aim of this study was to assess intraoperative cytology together with frozen section for accuracy, turnaround time, and total response time during video-assisted thoracic surgery. METHODS: We included patients having video-assisted thoracic surgery between August 2018 and February 2019 at our institution. A cytopathologist and a surgical pathologist independently performed intraoperative cytology and frozen sections, respectively. Final histologic diagnosis was the reference standard. Intraoperative cytology, frozen section turnaround, and total response times were analyzed. RESULTS: A total of 52 specimens from 27 patients were included. The intraoperative cytology correlated with final histology in 98% of cases. Frozen section correlated with final histology in 100% of cases. Intraoperative cytology turnaround and total response times were equal (mean, 4.35 minutes; range, 2-15 minutes). Mean frozen section turnaround and response times were 26.2 minutes (range, 9-61 minutes) and 36.7 minutes (range, 16-90 minutes), respectively. We found a statistically significant difference between intraoperative cytology and frozen section turnaround time and total response times (P < .001). CONCLUSIONS: This study highlights that intraoperative cytology could be as accurate as frozen section and considerably faster during video-assisted thoracic surgery (P < .001). Total response time could potentially be used as a quality metric for video-assisted thoracic surgery.

Mass-Forming Ischemic Colitis: A Potential Mimicker of Malignancy.

Ischemic colitis (IC) results from reduced colonic vascular perfusion, accounting for 50-60% of all gastrointestinal ischemic episodes. IC leads to mucosal damage with clinical symptom severity developing based on the duration and extent of colonic injury. In rare cases IC may form a mass-like lesion mimicking malignancy. Here we present the case of a 55-year-old female with hematochezia and diarrhea, who on workup was found to have a mass-like lesion at the ileocecal valve. Multiple biopsies demonstrated ischemic change and mucosal injury without evidence of dysplasia or carcinoma. Two months later on follow-up imaging, after supportive treatment the lesion was completely resolved. It is critical for gastroenterologists and pathologists to be aware of this variant of IC to avoid unnecessary surgical procedures and treatment of patients.

The Impact of Routine Frozen Section Assessment During Penectomy on Surgical Margin Status and Long-Term Oncologic Outcomes.

No recent studies have focused on assessing the role of intraoperative frozen section assessment (FSA) in the status of surgical margins (SMs) relating to the outcomes of penectomy cases. In this study, we investigated the utility of routine FSA of the SMs in men undergoing penectomy. A retrospective review identified consecutive patients who underwent partial (n = 26) or total (n = 12) penectomy for penile squamous cell carcinoma at our institution from 2004 to 2015. FSA of the SMs was performed in 21 (80.8%) partial and 10 (83.3%) total penectomies. FSAs were reported as positive (n = 3, 9.7%), atypical (n = 3, 9.7%), and negative (n = 25, 80.6%). All of the positive or negative FSA diagnoses were confirmed accurate on the frozen section controls, whereas the 3 cases with atypical FSA had non-malignant, atypical, and carcinoma cells, respectively, on the controls. Final SMs were positive in 6 (15.8%) penectomies, including 4 (12.9%) FSA cases versus 2 (28.6%) non-FSA cases (P = 0.569). Furthermore, initial positive (1 of 3) and atypical (3 of 3) FSA cases achieved negative conversion by excision of additional tissue sent for FSA. Kaplan-Meier analysis revealed that performing FSA or its number/diagnosis was not significantly associated with disease progression. Thus, performing FSA during penectomy does not appear to have any significant impact on final SM status nor long-term oncologic outcomes. However, as seen in at least 4 cases, select patients may benefit from the routine FSA.